October 9, 2018



New article by Dr. Andrea Gruneir
Care setting and 30-day hospital readmissions among older adults: a population-based cohort study
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A. Gruneir, K. Fung, H. D. Fischer, et al.
CMAJ 2018 Sep 24;190(38):E1124-E1133
Despite the fact that many older adults receive home or long-term care services, the effect of these care settings on hospital readmission is often overlooked. Efforts to reduce hospital readmissions, including capacity planning and targeting of interventions, require clear data on the frequency of and risk factors for readmission among different populations of older adults. METHODS: We identified all adults older than 65 years discharged from an unplanned medical hospital stay in Ontario between April 2008 and December 2015. We defined 2 preadmission care settings (community, long-term care) and 3 discharge care settings (community, home care, long-term care) and used multinomial regression to estimate associations with 30-day readmission (and death as a competing risk). RESULTS: We identified 701 527 individuals (mean age 78.4 yr), of whom 414 302 (59.1%) started in and returned to the community. Overall, 88 305 in dividuals (12.6%) were re admitted within 30 days, but this proportion varied by care setting combination. Relative to individuals returning to the community, those discharged to the community with home care (adjusted odds ratio [OR] 1.43, 95% confidence interval [CI] 1.39-1.46) and those returning to long-term care (adjusted OR 1.35, 95% CI 1.27-1.43) had a greater risk of readmission, whereas those newly admitted to long-term care had a lower risk of readmission (adjusted OR 0.68, 95% CI 0.63-0.72). INTERPRETATION: In Ontario, about 40% of older people were discharged from hospital to either home care or long-term care. These discharge settings, as well as whether an individual was admitted to hospital from long-term care, have important implications for understanding 30-day readmission rates. System planning and efforts to reduce readmission among older adults should take into account care settings at both admission and discharge.

New article by Dr. Ali Hutchinson
“Dignity”: A central construct in nursing home staff understandings of quality continence care.
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J. Ostaszkiewicz, E. Tomlinson and A. M. Hutchinson.
J Clin Nurs 2018 Jun;27(11-12):2425-2437
To explore nursing home staff members’ beliefs and expectations about what constitutes “quality continence care” for people living in nursing homes. BACKGROUND: Most nursing home residents require assistance to maintain continence or manage incontinence. Best practice guidelines promote active investigation of incontinence, treatment of underlying potentially reversible causes, and initial conservative interventions to prevent, minimise and/or treat incontinence. Despite research showing the positive benefits of implementing active interventions, translating the findings of research into practice in nursing homes has been modest. Understanding the perspectives of individuals who provide continence care may help bridge the gap between evidence and practice. DESIGN: A qualitative exploratory descriptive design. METHODS: Qualitative interviews were conducted with 19 nursing home staff: eight registered nurses, four enrolled nurses and seven personal care workers working in a nursing home in Australia between 2014-2015. Data were analysed inductively to identify themes and subthemes that described and explained staff beliefs about quality continence care in nursing homes. FINDINGS: Participants’ understanding and expectations about quality continence care were linked to beliefs about incontinence being an intractable and undignified condition in nursing homes. The key theme to emerge was “protecting residents’ dignity” which was supported by the following six subthemes: (i) using pads, ii) providing privacy, (iii) knowing how to “manage” incontinence, (iv) providing timely continence care, (v) considering residents’ continence care preferences and (vi) communicating sensitively. CONCLUSION: The findings provide new insight into the basis for continence care practices in nursing homes. Education about continence care should challenge beliefs that limit continence care practice to cleaning, containing and concealing incontinence. There is a need for a multidimensional framework that is informed by social, psychological and biomedical research about incontinence, research about the fundamental elements of care, care-dependent individuals’ expectations about care, and values about dignity and care. RELEVANCE TO CLINICAL PRACTICE: The in-depth exploration led to an understanding of the basis for continence care practices that centre on cleaning, containing and concealing residents’ incontinence in some nursing homes. There is a need to review the quality of education for the aged care workforce about incontinence to ensure it equips them with a broad understanding of the fundamentals of care and how to enact dignity in continence care through a resident-centred approach.

New article by Dr. Anne-Marie Boström
New parents’ experience of information and sense of security related to postnatal care: A systematic review
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I. Wiklund, J. Wiklund, V. Pettersson and A. M. Bostrom.
Sex Reprod Healthc 2018 Oct;17:35-42
Becoming a parent is often a tumultuous experience and a great challenge. The transition when a child is born is described affecting the parents and their relationship psychically, physically, mentally and emotionally. Information within care should be relevant and supportive. Furthermore information within the context of care should be relevant, supportive and helpful to parents in handling their new situation and increasing their self-reliance. AIM: To provide a contextualised understanding of how parents experience postnatal care in relation to information and sense of security”. METHOD: A systematic search was undertaken at PubMed and CINAHL database for literature published between January 2002 and August 2017. Inclusion criteria focused on postnatal care. Eight of the studies used qualitative methods and two of the studies used quantitative methods, as a result the findings could not be combined using meta-analysis or meta-synthesis, instead narrative synthesis of the findings were used. RESULTS: Ten studies were included. The analysis revealed three categories related to parent’s experience of information and sense of security during the postnatal period. These categories were; Expectations on the care; Own resources; and Confirmation. Support from staff and family is described as significant for the parents’ sense of security. During the first postnatal week, the emotions were characterized by anxiety and/or fear. Parents prefer a “non-judgmental” attitude from the staff and to be met as an individual. CONCLUSION: Family -centred care such as continuity, participation, individually adaptation, consistent, information and preparation for parenting appear to be important components for parents’ sense of security in postnatal care.

New article by Dr. Janet Squires and Dr. Lars Wallin
Managerial leadership for research use in nursing and allied health care professions: a systematic review
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W. A. Gifford, J. E. Squires, D. E. Angus, et al.
Implement Sci 2018 Sep 27;13(1):127-018-0817-7
Leadership by point-of-care and senior managers is increasingly recognized as critical to the acceptance and use of research evidence in practice. The purpose of this systematic review was to identify the leadership behaviours of managers that are associated with research use by clinical staff in nursing and allied health professionals. METHODS: A mixed methods systematic review was performed. Eight electronic bibliographic databases were searched. Studies examining the association between leadership behaviours and nurses and allied health professionals’ use of research were eligible for inclusion. Studies were excluded if leadership could not be clearly attributed to someone in a management position. Two reviewers independently screened abstracts, reviewed full-text articles, extracted data and performed quality assessments. Narrative synthesis was conducted. RESULTS: The search yielded 7019 unique titles and abstracts after duplicates were removed. Three hundred five full-text articles were reviewed, and 31 studies reported in 34 articles were included. Methods used were qualitative (n = 19), cross-sectional survey (n = 9), and mixed methods (n = 3). All studies included nurses, and six also included allied health professionals. Twelve leadership behaviours were extracted from the data for point-of-care managers and ten for senior managers. Findings indicated that managers performed a diverse range of leadership behaviours that encompassed change-oriented, relation-oriented and task-oriented behaviours. The most commonly described behavior was support for the change, which involved demonstrating conceptual and operational commitment to research-based practices. CONCLUSIONS: This systematic review adds to the growing body of evidence that indicates that manager-staff dyads are influential in translating research evidence into action. Findings also reveal that leadership for research use involves change and task-oriented behaviours that influence the environmental milieu and the organisational infrastructure that supports clinical care. While findings explain how managers enact leadership for research use, we now require robust methodological studies to determine which behaviours are effective in enabling research use with nurses and allied health professionals for high-quality evidence-based care. TRIAL REGISTRATION: PROSPERO CRD42014007660

New article by Dr. Kim Fraser
The association of perceived conflict with sadness for long-term care residents with moderate and severe dementia
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H. M. O’Rourke, K. D. Fraser, W. Duggleby and N. Keating.
Dementia (London) 2018 Oct;17(7):801-820
Research into the lived experiences of long-term care residents with dementia has identified perceived conflict, and its impact on sadness, as priorities for quality of life from the perspectives of people with dementia. However, whether and to what extent perceived conflict and sadness are associated has not been previously tested in this population. This study tested the associations between perceived conflicts with staff, family or friends and co-residents and their experience of sadness, and whether cognitive impairment or functional dependence modified these associations. Methods The study design was cross-sectional, correlational retrospective. Participants were 5001 residents of 613 long-term care facilities in Ontario, Canada with moderate and severe dementia. Clinical administrative data collected from 2012 to 2013 using the Resident Assessment Instrument 2.0 were used to measure the person’s perception of conflicts with family/friends, staff, or co-residents, as well as verbal and non-verbal indicators of sadness. Hypotheses were tested using logistic regression, with cluster correction. Results Sadness (adjusting for age, sex, family/friend contact, pain, cognitive impairment, and functional dependence) was positively associated with perceived conflicts with family or friends (OR 1.91; 95% CI 1.26-2.88; p = 0.002) and staff (OR 1.51; 95% CI 1.07-2.13; p = 0.020). These associations did not differ depending on the level of cognitive impairment or functional dependence. The association between co-resident conflict and sadness was statistically significant for people with moderate (OR 2.02; 95% CI 1.45-2.82; p < 0.001) but not for those with severe dementia (OR 1.18; 95% CI 0.72-1.91; p = 0.511). Conclusion Long-term care residents with dementia who perceive conflict with others require support to maintain high quality relationships, particularly with family and friends. Future research should rigorously assess the modifiability of perceived conflict for people with moderate and severe dementia, and whether interventions to ameliorate perceived conflict result in decreased sadness and improved quality of life.


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Health Care Administration and Organization
Health Care Innovation and Quality Assurance
Organizational Culture and Change
Research Practice and Methodology


The Long-lasting Effects of Newspaper Op-Eds on Public Opinion
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Alexander Coppock, Emily Ekins and David Kirby.
Quarterly Journal of Political Science 2018;13(1):59-87.
Do newspaper opinion pieces change the minds of those who read them? We conduct two randomized panel survey experiments on elite and mass convenience samples to estimate the effects of five op-eds on policy attitudes. We find very large average treatment effects on target issues, equivalent to shifts of approximately 0.5 scale points on a 7-point scale, that persist for at least one month. We find very small and insignificant average treatment effects on non-target issues, suggesting that our subjects read, understood, and were persuaded by the arguments presented in these op-eds. We find limited evidence of treatment effect heterogeneity by party identification: Democrats, Republicans, and independents all appear to move in the predicted direction by similar magnitudes. We conduct this study on both a sample of Amazon Mechanical Turk workers and a sample of elites. Despite large differences in demographics and initial political beliefs, we find that op-eds were persuasive to both the mass public and elites, but marginally more persuasive among the mass public. Our findings add to the growing body of evidence of the everyday nature of persuasion.

Agents of change: establishing quality improvement collaboratives to improve adherence to Australian clinical guidelines for dementia care
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M. Cations, M. Crotty, J. A. Fitzgerald, et al.
Implement Sci 2018 Sep 24;13(1):123-018-0820-z
Dissemination of clinical practice guidelines alone is insufficient to create meaningful change in clinical practice. Quality improvement collaborative models have potential to address the evidence-practice gap in dementia care because they capitalise on known knowledge translation enablers and incorporate optimal approaches to implementation. Non-pharmacological interventions focused on promoting independence are effective and favoured by people with dementia and their carers but are not routinely implemented. The objective of this translational project is to assess the impact of quality improvement collaboratives (QICs) on adherence to non-pharmacological recommendations from the Clinical Practice Guidelines for Dementia in Australia. METHODS: This project will employ an interrupted time-series design with process evaluation to assess the impact, uptake, feasibility, accessibility, cost, and sustainability of the QICs over 18 months. Thirty clinicians from across Australia will be invited to join the QICs to build their capacity in leading innovation in dementia care. Clinicians will participate in a training program and be supported to develop and implement a quality improvement project unique to their service context using plan-do-study-act cycles. Regular online meetings with their peers in the QIC will facilitate benchmarking and problem-solving. Clinicians will describe their practice via monthly checklists, and guideline adherence will be determined against a set of defined criteria. Phone interviews with up to 180 client dyads will be used to assess satisfaction with care and client outcomes. Clinician interviews and field note data will be used to explore implementation and costs. Involvement of people with dementia and carers will be embedded in the study design, conduct, and reporting, in addition to clinical and industry expertise. DISCUSSION: The quality of dementia care in Australia is largely dependent on the clinician involved and the extent to which they apply best available evidence in their practice. This study will determine the elements of this multifaceted implementation strategy that contributed to guideline adherence and client outcomes. The findings will inform future translational approaches to improving care and outcomes for people with dementia and their carers. TRIAL REGISTRATION: Registered with the Australian New Zealand Clinical Trials Registry 21 February 2018 ( ACTRN12618000268246 ).

Pathways to policy impact: a new approach for planning and evidencing research impact
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Mark S. Reed, Rosalind Bryce and Ruth Machen.
Evidence & Policy: A Journal of Research, Debate and Practice 2018;14(3):431-458
The use of research in policy settings is complex, unpredictable and influenced by a range of poorly understood social factors. This makes it difficult to plan for, facilitate and evaluate policy impacts arising from research. Aims and objectives 1. Propose and test tools for planning for and facilitating research impact, based on a new logic model combined with a novel approach to public/stakeholder analysis. 2. Propose and test methods for establishing causal links between research and policy impacts. 3. Use case study findings to provide new empirical insights into the social processes that mediate the generation of impact from research. Methods Social Network Analysis, qualitative analysis of semi-structured interviews, and analysis of secondary data were used in a case study of peatland climate change research in Scottish Government policy. Findings Boundary organisations and centrally-positioned, well-trusted individuals, were crucial to the development of a trusted body of research in which policymakers were sufficiently confident as the basis for policy. Discussion and conclusions The non-linear social dynamics that characterise science-policy networks can be understood and evaluated. By using the tools described in this paper, researchers and other stakeholders can better plan, facilitate and evaluate research impact.

Characteristics and behaviours of formal versus informal nurse champions and their relationship to innovation success
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S. Luz, E. Shadmi, H. Admi, I. Peterfreund and A. Drach-Zahavy.
J Adv Nurs 2018 Aug 30
AIMS: To identify the sociodemographic attributes, project characteristics and champion strategies that differentiate formal from informal nursing champions, and to test their success in terms of project spread and novelty. BACKGROUND: Champions spread innovation in healthcare organizations. Empirical research has not explored the differences between formal and informal champions in terms of their antecedents and success. DESIGN: A quantitative cross-sectional design. METHOD: Data were collected on 93 nursing champions in three hospitals from 2015 – 2016. Champions were identified according to a validated approach; data on their sociodemographic attributes, project characteristics and strategies were assembled through interviews and validated questionnaires. Their success in terms of novelty and spread was assessed via expert ratings and validated questionnaire. FINDINGS: Informal champions had longer tenure and were involved mainly in bottom-up projects aimed mostly at improving human resources and services; formal champions were mostly involved in top-down projects aimed at quality control. Informal champions expressed more enthusiasm and confidence about the innovation; formal champions tended to use more online resources and peer-monitoring strategies. Projects of informal champions were more novel than those of formal champions. Project spread did not differ between the two groups. CONCLUSION: Formal and informal champions differ in their characteristics and implementation strategies. To encourage project’s innovation, the organizational climate should encourage the emergence of informal champions; formal and informal champions should be chosen wisely, assuring that they possess enough organizational resources; and coaching programmes for junior champions should be planned to equip them with championing behaviours.


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Health Care Administration and Organization

Avoiding costly hospitalisation at end of life: findings from a specialist palliative care pilot in residential care for older adults.
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M. Chapman, N. Johnston, C. Lovell, L. Forbat and W. M. Liu.
BMJ Support Palliat Care 2018 Mar;8(1):102-109
Specialist palliative care is not a standardised component of service delivery in nursing home care in Australia. Specialist palliative care services can increase rates of advance care planning, decrease hospital admissions and improve symptom management in such facilities. New approaches are required to support nursing home residents in avoiding unnecessary hospitalisation and improving rates of dying in documented preferred place of death. This study examined whether the addition of a proactive model of specialist palliative care reduced resident transfer to the acute care setting, and achieved a reduction in hospital deaths. METHODS: A quasi-experimental design was adopted, with participants at 4 residential care facilities. The intervention involved a palliative care nurse practitioner leading ‘Palliative Care Needs Rounds’ to support clinical decision-making, education and training. Participants were matched with historical decedents using propensity scores based on age, sex, primary diagnosis, comorbidities and the Aged Care Funding Instrument rating. Outcome measures included participants’ hospitalisation in the past 3 months of life and the location of death. RESULTS: The data demonstrate that the intervention is associated with a substantial reduction in the length of hospital stays and a lower incidence of death in the acute care setting. While rates of hospitalisation were unchanged on average, length of admission was reduced by an average of 3.22 days (p<0.01 and 95% CI -5.05 to -1.41), a 67% decrease in admitted days. CONCLUSIONS: The findings have significant implications for promoting quality outcomes through models of palliative care service delivery in residential facilities.

Staff’s reactions towards partnered sexual expressions involving people with dementia living in long-term care facilities.
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F. Villar, M. Celdran, R. Serrat, J. Faba and T. Martinez.
J Adv Nurs 2018 May;74(5):1189-1198
To explore staff responses, in terms of common practices, towards partnered sexual relationships in long-term care facilities where one or both people involved have dementia. It also tries to determine personal and institutional factors influencing these responses. BACKGROUND: Although some studies, mostly qualitative, have focused on reactions to residents’ sexual expressions so far the issue has not been assessed in a study using large and diverse samples. DESIGN: Cross-sectional quantitative study using vignette technique. METHODS: Participants were 2,295 staff members at 152 Spanish long-term care facilities. Data were collected during 2016. A vignette describing sexual situations involving people with dementia was presented to participants. After the vignette, participants had to answer the question: “What do you think most of your colleagues would do in this situation?” with nine possible responses. RESULTS: Results showed that relationships involving persons with dementia were perceived as potentially problematic by staff. In both conditions, discussing the case with a colleague or supervisor was the most frequently chosen reaction. More restrictive reactions were mentioned when only one person with dementia was involved in the relationship. Factors such as participants” age and years of experience, professional post and commitment to person-centred care practices were related with the frequency of common restriction practices. CONCLUSION: Results highlight the importance of providing staff with clear guidelines regarding the management of specific sexual situations to avoid stereotyped restrictive reactions.

Implementing e-learning and e-tools for care home staff supporting residents with dementia and challenging behaviour: A process evaluation of the ResCare study using normalisation process theory
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J. Keenan, F. Poland, J. Manthorpe, C. Hart and E. Moniz-Cook.
Dementia (London) 2018 Sep 30:1471301218803195
Dementia-related symptoms, sometimes termed challenging or distressing behaviour, can give rise to significant distress in care homes. Individualised formulation-led interventions show promise in reducing these behaviours. ResCare, a cluster randomised controlled trial in England, tested an online individualised intervention, comprising e-learning and decision support e-tools, designed to enable staff to better support residents with such symptoms. Normalisation process theory was used to understand the implementation processes. We analysed contextual process data for all 27 ‘intervention’ care homes and identified three implementation mechanisms. These were examined for four illustrative case study homes. Seven qualitative interviews with care home staff and one interview with two research therapists informed this understanding. The main barrier to implementation was difficulty in conveying a sustained understanding of the value of individually tailored interventions. Emphasis was placed on training rather than practice change. Implementation seemed easier in smaller homes and in those with flexible managerial styles where transfer of knowledge and skill might have been easier to achieve. Take up of e-learning and e-tools proved hard. There may be a need to continually promote ‘buy-in’ of the potential benefits of individualised formulation-led interventions, and this would have to be congruent with other priorities. Interventions within care homes need to consider organisational readiness, capacity for innovation and ongoing appraisal and adjustment to maintain changes in practice.

Non‐job work/unpaid caring: Gendered industrial relations in long‐term care
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Donna Baines and Pat Armstrong.
Gender Work Organ 2018 09/21; 2018/10;0(0)
This article explores the operation of gender and industrial relations in long-term care work or nursing home work, ?from within? the experience of the predominantly female workforce in seven unionized facilities in Canada. Drawing on qualitative case study data in non-profit facilities, the article argues that the main industrial relations challenges facing long-term care workers are that their workplace priorities do not fit within existing, gendered, industrial relations processes and institutions. This article starts from the experience of women and threads this experience through other layers of social organization such as: global and local policy directions including austerity, New Public Management, and social and healthcare funding; industrial relations mechanisms and policy; and workers? formal union] and informal efforts to represent their interests in the workplace. The strongest themes in the reported experience of the women include: manufacturing conditions for unpaid work; increasing management and state dependence on unpaid care work; fostering loose boundaries; and limiting respect and autonomy as aspects of care work. The article extends the feminist political economy by analysing the links between the policies noted above and frontline care work. Building on gendered organizational theory the article also introduces the concept of non-job work and suggests a fourth industrial relations institution, namely the needs and gendered expectations of residents, families and workers themselves, operating within the liminal spaces in care work.

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Health Care Innovation and Quality Assurance

Quality Indicators of Primary Care Provider Engagement in Nursing Home Care
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Allison Moser Mays, Debra Saliba, Sid Feldman, et al.
Journal of the American Medical Directors Association 2018 10/01; 2018/09;19(10):824-832
The initiative described here aims to identify quality indicators (QIs) germane to the international practice of primary care providers (PCP) in post-acute and long-term care in order to demonstrate the added value of medical providers in nursing homes (NHs). A 7-member international team identified and adapted existing QIs to the AMDA competencies for medical providers. QI sources included the ACOVE 3 Quality Indicators (2007), NH Quality Indicators (2004), NH Residential Care Quality Indicators (2002), and AGS Choosing Wisely (2014). We recruited a technical expert panel (TEP) consisting of 11 panelists from the US, Canada, and the European Union, selected for their knowledge and leadership in post-acute and long-term care. The TEP, using a RAND Modified Delphi approach, provided pre-meeting ratings, discussed items in-person for clarification, and re-rated items following discussion. When panelists rated more than 1 option for a particular QI as valid and feasible, the most stringent option was selected for inclusion in the final candidate set of QIs. Panelists confidentially rated an initial 103 items on validity and feasibility of implementation. During the meeting, panelists added 18 QIs and modified 18. In post-meeting analysis, we eliminated 7 QIs rated not valid and 9 QIs for which a more stringent QI was rated valid and feasible. This resulted in a final set of 97 QIs rated valid and feasible and 8 rated valid but not feasible. This set of QIs for PCPs in the NH identified practices in which provider engagement adds value through expertise in geriatric syndromes, employing evidence-based practice, advocating for residents, delivering person-centered care, facilitating advance care planning, and communicating effectively to coordinate care. Next steps include pilot testing and evaluating the association between adherence to QIs, PCP staffing models, and better outcomes.; The initiative described here aims to identify quality indicators (QIs) germane to the international practice of primary care providers (PCP) in post-acute and long-term care in order to demonstrate the added value of medical providers in nursing homes (NHs). A 7-member international team identified and adapted existing QIs to the AMDA competencies for medical providers. QI sources included the ACOVE 3 Quality Indicators (2007), NH Quality Indicators (2004), NH Residential Care Quality Indicators (2002), and AGS Choosing Wisely (2014). We recruited a technical expert panel (TEP) consisting of 11 panelists from the US, Canada, and the European Union, selected for their knowledge and leadership in post-acute and long-term care. The TEP, using a RAND Modified Delphi approach, provided pre-meeting ratings, discussed items in-person for clarification, and re-rated items following discussion. When panelists rated more than 1 option for a particular QI as valid and feasible, the most stringent option was selected for inclusion in the final candidate set of QIs. Panelists confidentially rated an initial 103 items on validity and feasibility of implementation. During the meeting, panelists added 18 QIs and modified 18. In post-meeting analysis, we eliminated 7 QIs rated not valid and 9 QIs for which a more stringent QI was rated valid and feasible. This resulted in a final set of 97 QIs rated valid and feasible and 8 rated valid but not feasible. This set of QIs for PCPs in the NH identified practices in which provider engagement adds value through expertise in geriatric syndromes, employing evidence-based practice, advocating for residents, delivering person-centered care, facilitating advance care planning, and communicating effectively to coordinate care. Next steps include pilot testing and evaluating the association between adherence to QIs, PCP staffing models, and better outcomes.

Quality Clinical Care in Nursing Facilities.
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B. J. Zarowitz, B. Resnick and J. G. Ouslander.
J Am Med Dir Assoc 2018 Oct;19(10):833-839
Despite improvements in selected nursing facility (NF) quality measures such as reduction in antipsychotic use; local, state, and national initiatives; and regulatory incentives, the quality of clinical care delivered in this setting remains inconsistent. Herein, recommendations for overcoming barriers to achieving consistent, high-quality clinical outcomes in long-term (LTC) and post-acute care are provided to address inadequate workforce, suboptimal culture and interprofessional teamwork, insufficiently evidence-based processes of care, and poor adoption and fidelity of technology and integrated clinical decision support. With high staff attrition rates in NFs, mechanisms to measure and close knowledge gaps as well as opportunities for practice simulations should be available to educate and ensure adoption of clinical quality standards on clinician hiring and on an ongoing basis. Multipronged, integrated approaches are needed to further the quest for sustainment of high clinical quality in NF care. In addition to setting a tone for attainment of clinical quality, leadership should champion adoption of practice standards, quality initiatives, and evidence-based guidelines. Maintaining an optimal ratio of hours per resident per day of nurses and nurse aides can improve quality outcomes and staff satisfaction. Clinicians must consistently and effectively apply care processes that include recognition, problem definition, diagnosis, goal identification, intervention, and monitoring resident progress. In order to do so they must have rapid, easy access to necessary tools, including evidence-based standards, algorithms, care plans, during the care delivery process. Embedding such tools into workflow of electronic health records has the potential to improve quality outcomes. On a national and international level, quality standards should be developed by interprofessional LTC experts committed to applying the highest levels of clinical evidence to improve the care of older persons. The standards should be realistic and practical, and basic principles of implementation science must be used to achieve the desired outcomes.

Public/private ownership and quality of care: Evidence from Danish nursing homes.
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U. Hjelmar, Y. Bhatti, O. H. Petersen, T. Rostgaard and K. Vrangbaek.
Soc Sci Med 2018 Sep 18;216:41-49
The involvement of private for-profit (FP) and not-for-profit (NFP) providers in the otherwise public delivery of welfare services is gradually changing the Nordic welfare state towards a more market-oriented mode of service delivery. This article examines the relationship between ownership and quality of care in public and private FP and NFP nursing homes in Denmark. The analysis draws on original survey data and administrative registry data (quality inspection reports) for the full population of almost 1000 nursing homes in Denmark. Quality is measured in terms of structural quality, process quality and outcome quality. We find that public nursing homes have a higher structural quality (in terms of, for instance, staffing), while FP providers perform better in terms of process quality (e.g. in the form of individualised care). NFP providers perform well in terms of structural criteria such as employment of full-time staff and receive fewer critical comments in the inspection reports. However, the results depend to some extent upon the method of data collection, which underlines the benefits of using multiple data sources to examine the relationship between ownership and the quality of care.

The impact of providing enhanced support for care home residents in Rushcliffe (UK)

Health Foundation, 2018
This briefing looks at the impact of a package of enhanced support for older people living in care homes. It finds that care home residents who received the enhanced support were admitted to hospital as an emergency 23% less often than similar residents in other parts of the country. The analysis in the briefing was conducted by the Improvement Analytics Unit, a partnership between NHS England and the Health Foundation. About this briefing The analysis within this briefing was conducted by the Improvement Analytics Unit, a partnership between NHS England and the Health Foundation. This Health Foundation briefing considers the findings of the analysis. The briefing looks at the impact of a package of enhanced support for older people living in care homes. The enhanced support was introduced in April 2014 and was developed by Principia, a local partnership of general practitioners, patients and community services that aims to provide better quality of care for people in Rushcliffe in Nottinghamshire, England. The briefing outlines the enhanced support package, then describes the methods the Improvement Analytics Unit used to derive the linked data used in the analysis, select a matched comparison group, and compare hospital utilisation between the two groups. The briefing describes the results of the analysis and discusses the findings. It concludes by looking at the implications and priorities for future research and improvement activity.


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Organizational Culture and Change

Individual innovation adoption and the role of organizational culture
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K. L. Heinze and J. E. Heinze.
Review of Managerial Science 2018
Technological innovations are generally considered to contribute positively to the organization, but there are gaps in our understanding of how benefits can be realized. In particular, studies of technological innovation adoption in organizations tend to focus on structural aspects of adoption and top-down, organization-wide implementation. Building on this work, we examine the relationship between organizational culture and individuals’ extent of adoption (frequency of using technology features). Using a survey of 1000 physicians in the USA, we studied the association between perceived organizational innovativeness and cohesiveness and the extent to which physicians adopt electronic health records. We found that organizational innovativeness was positively associated with individuals’ extent of adoption, and that this relationship was mediated by going to others for advice regarding the technology. Our findings were supported by interview data.

Learning from experience in a National Healthcare System: organizational dynamics that enable or inhibit change processes
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M. Dalmas and J. G. Azzopardi.
Int J Qual Health Care 2018 Sep 21
To study the organizational dynamics that either enable or inhibit the changes needed by the system for the ongoing organizational development of the major acute general public hospital in Malta. Setting: The main public acute general hospital in Malta. Malta is the main island of a small archipelago in the Mediterranean with a total population reaching around 460 000. Design and participants: This qualitative study utilized two major research methods: action research and in-depth interviews. Data collection and analysis were guided by the grounded theory paradigm and operated within a constructivist and informed grounded theory approach. The action research was conducted through the documentation and interpretation of a practitioner-researcher experience working within a multi-disciplinary hospital team consisting of up to 15 members from different healthcare professional groups. The in-depth interviews involved 25 interviewees using theoretical sampling techniques. Results: The findings affirmed the high potential and capabilities of the hospital workforce. This potential is nonetheless susceptible to be affected and gradually transformed by identified organizational and external forces into a workforce that is highly territorial, cynical and showing lack of ‘ownership’ of the organizational vision and objectives. The organizational culture, structures, systems and leadership as well as external factors that were frequently rooted at the national level were identified as strong impacting and underlying factors. Conclusions: A theoretical framework was generated depicting a vicious circle that needs to be broken to enable the desired organizational development and learning. This additional knowledge can be used by and inspire other organizations operating within comparable conditions.

Exploring what teams perceive by ‘culture’ when implementing new models of care.
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E. R. Bull, L. M. T. Byrne-Davis, J. Swift, K. Baxter, N. McLauchlan and J. K. Hart.
Int J Qual Health Care 2018 Sep 19
Health and social care organizations continually face change to coordinate efforts, improve care quality and better meet patient needs in the context of growing pressure on services. NHS ‘vanguard’ teams funded to pilot organizational change in England have argued that alongside new structures, policies and governance, a shift in ‘workplace culture’ is needed to implement change. Although now defined in the literature and seen as an important driver of quality care, it was not clear what teams themselves meant when discussing workplace culture. Methods: In a qualitative study nested in a wider behavioural science programme, 34 managers and frontline NHS staff took part in interviews and focus groups on the role and meaning of ‘workplace culture’ in their experience of change. Participants were from organizations in four NHS England vanguards implementing new models of care. Inductive thematic analysis revealed six interlinking themes: unity, emotions, support, consistency, openness to innovation and performance. Results: The term ‘workplace culture’ was nuanced and used in various ways. It was seen as a determinant, measure and/or consequence of change and linked to workplace behaviours, emotions and cognitions. Participants agreed that imposed top-down change in new models of care was a common cause of damaged culture and had knock-on effects on care quality, despite manager accounts of the importance of staff ideas. Discussion: Our findings suggest that exploring teams’ own meanings of culture and behaviour change barriers, gathering ideas and co-developing tailored support would help overcome cultural challenges in implementing new models of care.

Better hospital context increases success of care pathway implementation on achieving greater teamwork: a multicenter study on STEMI care.
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D. Aeyels, L. Bruyneel, D. Seys, et al.
Int J Qual Health Care 2018 Sep 19
To evaluate whether hospital context influences the effect of care pathway implementation on teamwork processes and output in STEMI care. Design: A multicenter pre-post intervention study. Setting: Eleven acute hospitals. Participants: Cardiologists-in-chief, nurse managers, quality staff, quality managers and program managers reported on hospital context. Teamwork was rated by professional groups (medical doctors, nurses, allied health professionals, other) in the following departments: emergency room, catheterization lab, coronary care unit, cardiology ward and rehabilitation. Intervention: Care pathway covering in-hospital care from emergency services to rehabilitation. Main outcome measures: Hospital context was measured by the five dimensions of the Model for Understanding Success in Quality: microsystem, quality improvement team, quality improvement support, high-level organization, external environment. Teamwork process measures reflected teamwork between professional groups within departments and teamwork between departments. Teamwork output was measured through the level of organized care. Two-level regression analysis accounted for clustering of respondents within hospitals and assessed the influence of hospital context on the impact of care pathway implementation on teamwork. Results: Care pathway implementation significantly improved teamwork processes both between professional groups (P < 0.001) and between departments (P < 0.001). Teamwork output also improved (P < 0.001). The effect of care pathway implementation on teamwork was more pronounced when the quality improvement team and quality improvement support and capacity were more positively reported on. Conclusions: Hospitals can leverage the effect of quality improvement interventions such as care pathways by evaluating and improving aspects of hospital context.

The Prevalence of Culture Change Practice in US Nursing Homes: Findings From a 2016/2017 Nationwide Survey.
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S. C. Miller, M. L. Schwartz, J. C. Lima, et al.
Med Care 2018 Sep 18
Given the dynamic nursing home (NH) industry and evolving regulatory environment, depiction of contemporary NH culture-change (person/resident-centered) care practice is of interest. Thus, we aimed to portray the 2016/2017 prevalence of NH culture change-related processes and structures and to identify factors associated with greater practice prevalence. RESEARCH DESIGN AND METHODS: We administered a nationwide survey to 2142 NH Administrators at NHs previously responding to a 2009/2010 survey. Seventy-four percent of administrators (1583) responded (with no detectable nonresponse bias) enabling us to generalize (weighted) findings to US NHs. From responses, we created index scores for practice domains of resident-centered care, staff empowerment, physical environment, leadership, and family and community engagement. Facility-level covariate data came from the survey and the Certification and Survey Provider Enhanced Reporting system. Ordered logistic regression identified the factors associated with higher index scores. RESULTS: Eighty-eight percent of administrators reported some facility-level involvement in NH culture change, with higher reported involvement consistently associated with higher domain index scores. NHs performed the best (82.6/100 weighted points) on the standardized resident-centered care practices index, and had the lowest scores (54.8) on the family and community engagement index. Multivariable results indicate higher index scores in NHs with higher leadership scores and in states having Medicaid pay-for-performance with culture change-related quality measures. CONCLUSIONS: The relatively higher resident-centered care scores (compared with other domain scores) suggest an emphasis on person-centered care in many US NHs. Findings also support pay-for-performance as a potential mechanism to incentivize preferred NH practice.

Successful Organizational Change: Integrating the Management Practice and Scholarly Literatures
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Jeroen Stouten, Denise M. Rousseau and David De Cremer.
ANNALS 2018 06/01; 2018/10;12(2):752-788
Contemporary organizations often struggle to create meaningful, sustainable changes. At the same time, relevant organizational research lacks an easily accessible consensus on basic change management processes and principles. One consequence is practitioner reliance on popular change models that more often cite expert opinion as their foundation rather than scientific evidence. This article reviews both key tenets of widely used practitioner-oriented change models and findings from scholarly research on organizational change processes to develop an integrative summary of the available evidence of what is known, contested, untested, and underused in change management. It identifies ten evidence-based steps in managing planned organizational change along with implications for research and practice.; Contemporary organizations often struggle to create meaningful, sustainable changes. At the same time, relevant organizational research lacks an easily accessible consensus on basic change management processes and principles. One consequence is practitioner reliance on popular change models that more often cite expert opinion as their foundation rather than scientific evidence. This article reviews both key tenets of widely used practitioner-oriented change models and findings from scholarly research on organizational change processes to develop an integrative summary of the available evidence of what is known, contested, untested, and underused in change management. It identifies ten evidence-based steps in managing planned organizational change along with implications for research and practice.

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Research Practice and Methodology

Aligning Evidence-Based Practice With Translational Research: Opportunities for Clinical Practice Research
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M. E. Weiss, K. L. Bobay, M. Johantgen and M. R. Shirey.
J Nurs Adm 2018 Sep;48(9):425-431
Magnet(R) and other organizations investing resources in evidence-based practice (EBP) are ideal laboratories for translational nursing research. Translational research, the study of implementation of evidence into practice, provides a unique opportunity to leverage local EBP work for maximum impact. Aligning EBP projects with rigorous translational research can efficiently meet both EBP and research requirements for Magnet designation or redesignation, inform clinical practice, and place organizations at the leading edge of practice-based knowledge development for the nursing discipline.

Uncovering the mechanisms of research capacity development in health and social care: a realist synthesis.
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J. Cooke, P. Gardois and A. Booth.
Health Res Policy Syst 2018 Sep 21;16(1):93-018-0363-4
Research capacity development (RCD) is considered fundamental to closing the evidence-practice gap, thereby contributing to health, wealth and knowledge for practice. Numerous frameworks and models have been proposed for RCD, but there is little evidence of what works for whom and under what circumstances. There is a need to identify mechanisms by which candidate interventions or clusters of interventions might achieve RCD and contribute to societal impact, thereby proving meaningful to stakeholders. METHODS: A realist synthesis was used to develop programme theories for RCD. Structured database searches were conducted across seven databases to identify papers examining RCD in a health or social care context (1998-2013). In addition, citation searches for 10 key articles (citation pearls) were conducted across Google Scholar and Web of Science. Of 214 included articles, 116 reported on specific interventions or initiatives or their evaluation. The remaining 98 articles were discussion papers or explicitly sought to make a theoretical contribution. A core set of 36 RCD theoretical and conceptual papers were selected and analysed to generate mechanisms that map across macro contexts (individual, team, organisational, network). Data were extracted by means of ‘If-Then’ statements into an Excel spreadsheet. Models and frameworks were deconstructed into their original elements. RESULTS: Eight overarching programme theories were identified featuring mechanisms that were triggered across multiple contexts. Three of these fulfilled a symbolic role in signalling the importance of RCD (e.g. positive role models, signal importance, make a difference), whilst the remainder were more functional (e.g. liberate talents, release resource, exceed sum of parts, learning by doing and co-production of knowledge). Outcomes from one mechanism produced changes in context to stimulate mechanisms in other activities. The eight programme theories were validated with findings from 10 systematic reviews (2014-2017). CONCLUSIONS: This realist synthesis is the starting point for constructing an RCD framework shaped by these programme theories. Future work is required to further test and refine these findings against empirical data from intervention studies.

Role of feasibility and pilot studies in randomised controlled trials: a cross-sectional study
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A. J. Blatch-Jones, W. Pek, E. Kirkpatrick and M. Ashton-Key.
BMJ Open 2018 Sep 25;8(9):e022233-2018-022233
To assess the value of pilot and feasibility studies to randomised controlled trials (RCTs) funded by the National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme. To explore the methodological components of pilot/feasibility studies and how they inform full RCTs. STUDY DESIGN: Cross-sectional study. SETTING: Both groups included NIHR HTA programme funded studies in the period 1 January 2010-31 December 2014 (decision date). Group 1: stand-alone pilot/feasibility studies published in the HTA Journal or accepted for publication. Group 2: all funded RCT applications funded by the HTA programme, including reference to an internal and/or external pilot/feasibility study. The methodological components were assessed using an adapted framework from a previous study. MAIN OUTCOME MEASURES: The proportion of stand-alone pilot and feasibility studies which recommended proceeding to full trial and what study elements were assessed. The proportion of ‘HTA funded’ trials which used internal and external pilot and feasibility studies to inform the design of the trial. RESULTS: Group 1 identified 15 stand-alone pilot/feasibility studies. Study elements most commonly assessed were testing recruitment (100% in both groups), feasibility (83%, 100%) and suggestions for further study/investigation (83%, 100%). Group 2 identified 161 ‘HTA funded’ applications: 59 cited an external pilot/feasibility study where testing recruitment (50%, 73%) and feasibility (42%, 73%) were the most commonly reported study elements: 92 reported an internal pilot/feasibility study where testing recruitment (93%, 100%) and feasibility (44%, 92%) were the most common study elements reported. CONCLUSIONS: ‘HTA funded’ research which includes pilot and feasibility studies assesses a variety of study elements. Pilot and feasibility studies serve an important role when determining the most appropriate trial design. However, how they are reported and in what context requires caution when interpreting the findings and delivering a definitive trial.

Half-Life Your Message: A Quick, Flexible Tool for Message Discovery
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Elyse L. Aurbach, Katherine E. Prater, Brandon Patterson and Brian Zikmund-Fisher.
Science Communication 2018 10/01; 2018/09;40(5):669-677
Academic writers and presenters need concrete activities to help them learn how to communicate more effectively. We describe such a tool, called ?Half-Life Your Message,? which is adapted from a commonly used improvisational theater game and can be applied in three minutes to distill a central thesis for any communication effort. Users can increase the value provided by Half-Life Your Message by scaffolding its application with an introduction and opportunity to self-reflect and debrief. We emphasize the tool?s utility based on our experiences in using it ourselves and in teaching it to undergraduates, graduate students, and faculty.

Unpacking action research and implementation science: Implications for nursing
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M. Casey, D. O’Leary and D. Coghlan.
J Adv Nurs 2018 May;74(5):1051-1058
The aim of this study was to unpack the key concepts of action research and implementation science thereby enabling appropriate use of these methods in nursing. BACKGROUND: A key issue in action research is not so much the methodology employed to gather data/evidence but who decides the research agenda and who benefits from it. Implementation science is a way to ensure that evidence is translated into practice. The question arises as to how action research and implementation may be understood in relation to one another in nursing. DESIGN: Discussion Paper DATA SOURCES: This discussion paper is based on our own experiences and offers an exploration of action research and implementation science with the aim of clarifying what each involves and what synergies, if any, exist between them. IMPLICATIONS FOR NURSING: Using action research to secure the voice of patients in their own care is essential to delivering quality nursing care. Using implementation science frameworks to get research evidence into practice is effective. Familiarity with both these concepts may enable their improved use and have a positive impact on quality of care. CONCLUSION: There is a tension between action researchers and the protagonists of implementation science related to perceived “trade offs” between what constitutes “science” and the necessity of community participation. Nevertheless, the use of an implementation science framework in an action research approach can reduce the research practice time lag and action research provides sound theoretical and philosophical underpinnings that can be used by those in the implementation science field.

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Dysphagia in Nursing Home Residents: Management and Outcomes.
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N. Jukic Peladic, P. Orlandoni, G. Dell’Aquila, et al.
J Am Med Dir Assoc 2018 Sep 21
To define the prevalence of dysphagia and its associated factors and to investigate the influence of dysphagia and nutritional therapies performed in dysphagic subjects on clinical outcomes, including nutritional status, pressure ulcers, hospitalization, and mortality. DESIGN: A prospective observational study. SETTING AND PARTICIPANTS: Thirty-one Italian nursing homes participating in the ULISSE project and 1490 long-stay nursing home residents, older than 65 years, assessed at baseline and reassessed after 6 and 12 months. MEASURES: All participants underwent a standardized comprehensive assessment using the Italian version of the nursing home Minimum Data Set. The activities of daily living Long-Form scale was used to evaluate functional status. Health care professionals assessed dysphagia by means of clinical evaluation. Nutritional status was assessed using the information on weight loss. RESULTS: The prevalence of dysphagia was 12.8%, and 16% of the subjects were treated with artificial nutrition. The mortality rate in subjects with dysphagia was significantly higher compared with that of nondysphagic subjects (27.7% vs 16.8%; P = .0001). The prevalence of weight loss and pressure ulcers was also higher in dysphagic subjects. At variance, dysphagia was not associated with a higher hospitalization risk. CONCLUSION/IMPLICATIONS: Dysphagia is common in nursing home residents, and it is associated with higher mortality. Therefore, early diagnosis and optimal management of dysphagia should become a priority issue in nursing homes.

Exploring Antipsychotic Prescribing Behaviors for Nursing Home Residents With Dementia: A Qualitative Study.
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K. A. Walsh, C. Sinnott, A. Fleming, et al.
J Am Med Dir Assoc 2018 Sep 18
Caution is advised when prescribing antipsychotics to people with dementia. This study explored the determinants of appropriate, evidence-based antipsychotic prescribing behaviors for nursing home residents with dementia, with a view to informing future quality improvement efforts and behavior change interventions. DESIGN: Semistructured qualitative interviews based on the Theoretical Domains Framework (TDF). SETTING AND PARTICIPANTS: A purposive sample of 27 participants from 4 nursing homes, involved in the care of nursing home residents with dementia (8 nurses, 5 general practitioners, 5 healthcare assistants, 3 family members, 2 pharmacists, 2 consultant geriatricians, and 2 consultant psychiatrists of old age) in a Southern region of Ireland. MEASURES: Using framework analysis, the predominant TDF domains and determinants influencing these behaviors were identified, and explanatory themes developed. RESULTS: Nine predominant TDF domains were identified as influencing appropriate antipsychotic prescribing behaviors. Participants’ effort to achieve “a fine balance” between the risks and benefits of antipsychotics was identified as the cross-cutting theme that underpinned many of the behavioral determinants. On one hand, neither healthcare workers nor family members wanted to see residents over-sedated and without a quality of life. Conversely, the reality of needing to protect staff, family members, and residents from potentially dangerous behavioral symptoms, in a resource-poor environment, was emphasized. The implementation of best-practice guidelines was illustrated through 3 explanatory themes (“human suffering”; “the interface between resident and nursing home”; and “power and knowledge: complex stakeholder dynamics”), which conceptualize how different nursing homes strike this “fine balance.” CONCLUSIONS: Implementing evidence-based antipsychotic prescribing practices for nursing home residents with dementia remains a significant challenge. Greater policy and institutional support is required to help stakeholders strike that “fine balance” and ultimately make better prescribing decisions. This study has generated a deeper understanding of this complex issue and will inform the development of an evidence-based intervention.

Technical-efficiency analysis of end-of-life care in long-term care facilities within Europe: A cross-sectional study of deceased residents in 6 EU countries (PACE).
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A. B. Wichmann, E. M. M. Adang, K. C. P. Vissers, et al.
PLoS One 2018 Sep 25;13(9):e0204120
An ageing population in the EU leads to a higher need of long-term institutional care at the end of life. At the same time, healthcare costs rise while resources remain limited. Consequently, an urgency to extend our knowledge on factors affecting efficiency of long-term care facilities (LTCFs) arises. This study aims to investigate and explain variation in technical efficiency of end-of-life care within and between LTCFs of six EU countries: Belgium (Flanders), England, Finland, Italy, the Netherlands and Poland. In this study, technical efficiency reflects the LTCFs’ ability to obtain maximal quality of life (QoL) and quality of dying (QoD) for residents from a given set of resource inputs (personnel and capacity). METHODS: Cross-sectional data were collected by means of questionnaires on deceased residents identified by LTCFs over a three-month period. An output-oriented data-envelopment analysis (DEA) was performed, producing efficiency scores, incorporating personnel and capacity as input and QoL and QoD as output. Scenario analysis was conducted. Regression analysis was performed on explanatory (country, LTCF type, ownership, availability of palliative care and opioids) and case mix (disease severity) variables. RESULTS: 133 LTCFs of only one type (onsite nurses and offsite GPs) were considered in order to reduce heterogeneity. Variation in LTCF efficiency was found across as well as within countries. This variation was not explained by country, ownership, availability of palliative care or opioids. However, in the ‘hands-on care at the bedside’ scenario, i.e. only taking into account nursing and care assistants as input, Poland (p = 0.00) and Finland (p = 0.04) seemed to be most efficient. CONCLUSIONS: Efficiency of LTCFs differed extensively across as well as within countries, indicating room for considerable efficiency improvement. Our findings should be interpreted cautiously, as comprehensive comparative EU-wide research is challenging as it is influenced by many factors.

Modifying the consistency of food and fluids for swallowing difficulties in dementia.
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E. Flynn, C. H. Smith, C. D. Walsh and M. Walshe.
Cochrane Database Syst Rev 2018 Sep 24;9:CD011077
People with dementia can have feeding and swallowing difficulties (dysphagia). Modification of the consistency of food or fluids, or both, is a common management strategy. However, diet modification can affect quality of life and may lead to dehydration and malnutrition. Evidence on the benefits and risks of modifying food and fluids is mandatory to improve the care of people with dementia and dysphagia. OBJECTIVES: To determine the effectiveness and adverse effects associated with modifying the consistency of food and fluids in improving oral intake and eliminating aspiration in adults with dysphagia and dementia. SEARCH METHODS: We searched ALOIS (the Specialised Register of the Cochrane Dementia and Cognitive Improvement Group), the Cochrane Library, MEDLINE via Ovid SP, Embase via Ovid SP, PsycINFO via Ovid SP, CINAHL via EBSCOhost, LILACS via BIREME, ClinicalTrials.gov and the World Health Organization (WHO) Portal on 9 May 2018. We also checked the reference lists of relevant articles to identify any additional studies. SELECTION CRITERIA: We included randomised controlled trials (RCTs), quasi-RCTs and cluster-RCTs published in any language that measured any of the outcomes of interest. We included trials with adults with a clinical diagnosis of dementia with symptoms and signs of dysphagia confirmed on instrumental assessment. We included participants with all types, stages and severities of dementia. Control groups received either no intervention or interventions not involving diet modification or modification to sensory properties of food. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed for inclusion all potential studies identified. Data were extracted independently along with assessment of methodological quality using standard Cochrane methods. We contacted study authors for additional unpublished information. MAIN RESULTS: No trials on modification of food met the inclusion criteria. We included two studies that examined modification to fluids. Both were part of the same large multicentre trial and included people with dementia and people with or without dementia and Parkinson’s disease. Participation in the second trial was determined by results from the first trial. With unpublished data supplied by study authors, we examined data from participants with dementia only. The first study, a cross-over trial, investigated the immediate effects on aspiration of two viscosities of liquids (nectar thick and honey thick) compared to regular liquids in 351 participants with dementia using videofluoroscopy. Regular liquids with a chin down head posture, as well as regular liquids without any intervention were also compared. The sequence of interventions during videofluoroscopy may have influenced response to intervention. The second study, a parallel designed RCT, compared the effect of nectar and honey thick liquids with a chin down head posture over a three-month period in a subgroup of 260 participants with dementia. Outcomes were pneumonia and adverse intervention effects. Honey thick liquids, which are more consistent with descriptors for ‘spoon thick’ or ‘extremely thick’ liquids, showed a more positive impact on immediate elimination of aspiration during videofluoroscopy, but this consistency showed more adverse effects in the second follow-up study. During the second three-month follow-up trial, there were a greater number of incidents of pneumonia in participants receiving honey thick liquids than those receiving nectar thick liquids or taking regular liquids with a chin down posture. There were no deaths classified as ‘definitely related’ to the type of fluids prescribed. Neither trial addressed quality of life. Risk of bias for both studies is high. The overall quality of evidence for outcomes in this review is low. AUTHORS’ CONCLUSIONS: We are uncertain about the immediate and long-term effects of modifying the consistency of fluid for swallowing difficulties in dementia as too few studies have been completed. There may be differences in outcomes depending on the grade of thickness of fluids and the sequence of interventions trialled in videofluoroscopy for people with dementia. Clinicians should be aware that while thickening fluids may have an immediate positive effect on swallowing, the long-term impact of thickened fluids on the health of the person with dementia should be considered. Further high-quality clinical trials are required.

Meaningful connections in dementia end of life care in long term care homes.
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L. McCleary, G. N. Thompson, L. Venturato, et al.
BMC Psychiatry 2018 Sep 24;18(1):307-018-1882-9
Most persons with dementia die in long term care (LTC) homes, where palliative approaches are appropriate. However, palliative approaches have not been widely implemented and there is limited understanding of staff and family experiences of dying and bereavement in this context. METHOD: This descriptive qualitative study explored family and staff experiences of end of life and end of life care for persons with dementia in LTC homes. Eighteen focus groups were conducted with 77 staff members and 19 relatives of persons with dementia at four LTC homes in four Canadian provinces. RESULTS: Three themes emerged: knowing the resident, the understanding that they are all human beings, and the long slow decline and death of residents with dementia. DISCUSSION: Intimate knowledge of the person with dementia, obtained through longstanding relationships, was foundational for person-centred end of life care. Health care aides need to be included in end of life care planning to take advantage of their knowledge of residents with dementia. There were unmet bereavement support needs among staff, particularly health care aides. Persons with dementia were affected by death around them and existing rituals for marking deaths in LTC homes may not fit their needs. Staff were uncomfortable answering relatives’ questions about end of life. CONCLUSIONS: Longstanding intimate relationships enhanced end of life care but left health care aides with unmet bereavement support needs. Staff in LTC homes should be supported to answer questions about the trajectory of decline of dementia and death. Further research about residents’ experiences of deaths of other residents is needed.

Quality of dying and quality of end-of-life care of nursing home residents in six countries: An epidemiological study.
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L. Pivodic, T. Smets, N. Van den Noortgate, et al.
Palliat Med 2018 Oct 1:269216318800610
Nursing homes are among the most common places of death in many countries. AIM: To determine the quality of dying and end-of-life care of nursing home residents in six European countries. DESIGN: Epidemiological survey in a proportionally stratified random sample of nursing homes. We identified all deaths of residents of the preceding 3-month period. MAIN OUTCOMES: quality of dying in the last week of life (measured using End-of-Life in Dementia Scales – Comfort Assessment while Dying (EOLD-CAD)); quality of end-of-life care in the last month of life (measured using Quality of Dying in Long-Term Care (QoD-LTC) scale). Higher scores indicate better quality. SETTING/PARTICIPANTS: Three hundred and twenty-two nursing homes in Belgium, Finland, Italy, the Netherlands, Poland and England. Participants were staff (nurses or care assistants) most involved in each resident’s care. RESULTS: Staff returned questionnaires regarding 1384 (81.6%) of 1696 deceased residents. The End-of-Life in Dementia Scales – Comfort Assessment while Dying mean score (95% confidence interval) (theoretical 14-42) ranged from 29.9 (27.6; 32.2) in Italy to 33.9 (31.5; 36.3) in England. The Quality of Dying in Long-Term Care mean score (95% confidence interval) (theoretical 11-55) ranged from 35.0 (31.8; 38.3) in Italy to 44.1 (40.7; 47.4) in England. A higher End-of-Life in Dementia Scales – Comfort Assessment while Dying score was associated with country ( p = 0.027), older age ( p = 0.012), length of stay 1 year ( p = 0.034), higher functional status ( p < 0.001). A higher Quality of Dying in Long-Term Care score was associated with country ( p < 0.001), older age ( p < 0.001), length of stay 1 year ( p < 0.001), higher functional status ( p = 0.002), absence of dementia ( p = 0.001), death in nursing home ( p = 0.033). CONCLUSION: The quality of dying and quality of end-of-life care in nursing homes in the countries studied are not optimal. This includes countries with high levels of palliative care development in nursing homes such as Belgium, the Netherlands and England.

Oral care measures for preventing nursing home-acquired pneumonia.
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C. Liu, Y. Cao, J. Lin, et al.
Cochrane Database Syst Rev 2018 Sep 27;9:CD012416
Pneumonia occurring in residents of long-term care facilities and nursing homes can be termed ‘nursing home-acquired pneumonia’ (NHAP). NHAP is the leading cause of mortality among residents. NHAP may be caused by aspiration of oropharyngeal flora into the lung, and by failure of the individual’s defence mechanisms to eliminate the aspirated bacteria. Oral care measures to remove or disrupt oral plaque might be effective in reducing the risk of NHAP. OBJECTIVES: To assess effects of oral care measures for preventing nursing home-acquired pneumonia in residents of nursing homes and other long-term care facilities. SEARCH METHODS: Cochrane Oral Health’s Information Specialist searched the following databases: Cochrane Oral Health’s Trials Register (to 15 November 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2017, Issue 10), MEDLINE Ovid (1946 to 15 November 2017), and Embase Ovid (1980 to 15 November 2017) and Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1937 to 15 November 2017). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. We also searched the Chinese Biomedical Literature Database, the China National Knowledge Infrastructure, and the Sciencepaper Online to 20 November 2017. SELECTION CRITERIA: We included randomised controlled trials (RCTs) that evaluated the effects of oral care measures (brushing, swabbing, denture cleaning mouthrinse, or combination) in residents of any age in nursing homes and other long-term care facilities. DATA COLLECTION AND ANALYSIS: At least two review authors independently assessed search results, extracted data, and assessed risk of bias in the included studies. We contacted study authors for additional information. We pooled data from studies with similar interventions and outcomes. We reported risk ratio (RR) for dichotomous outcomes, mean difference (MD) for continuous outcomes, and hazard ratio (HR) for time-to-event outcomes, using random-effects models. MAIN RESULTS: We included four RCTs (3905 participants), all of which were at high risk of bias. The studies all evaluated one comparison: professional oral care versus usual oral care. We did not pool the results from one study (N = 834 participants), which was stopped at interim analysis due to lack of a clear difference between groups.We were unable to determine whether professional oral care resulted in a lower incidence rate of NHAP compared with usual oral care over an 18-month period (hazard ratio 0.65, 95% CI 0.29 to 1.46; one study, 2513 participants analysed; low-quality evidence).We were also unable to determine whether professional oral care resulted in a lower number of first episodes of pneumonia compared with usual care over a 24-month period (RR 0.61, 95% CI 0.37 to 1.01; one study, 366 participants analysed; low-quality evidence).There was low-quality evidence from two studies that professional oral care may reduce the risk of pneumonia-associated mortality compared with usual oral care at 24-month follow-up (RR 0.41, 95% CI 0.24 to 0.72, 507 participants analysed).We were uncertain whether or not professional oral care may reduce all-cause mortality compared to usual care, when measured at 24-month follow-up (RR 0.55, 95% CI 0.27 to 1.15; one study, 141 participants analysed; very low-quality evidence).Only one study (834 participants randomised) measured adverse effects of the interventions. The study identified no serious events and 64 non-serious events, the most common of which were oral cavity disturbances (not defined) and dental staining.No studies evaluated oral care versus no oral care. AUTHORS’ CONCLUSIONS: Although low-quality evidence suggests that professional oral care could reduce mortality due to pneumonia in nursing home residents when compared to usual care, this finding must be considered with caution. Evidence for other outcomes is inconclusive. We found no high-quality evidence to determine which oral care measures are most effective for reducing nursing home-acquired pneumonia. Further trials are needed to draw reliable conclusions.

Physical and mental health status and their correlations among older wheelchair users with dementia in long-term care facilities.
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C. L. Chang and K. M. Chen.
Qual Life Res 2018 Mar;27(3):793-800
To investigate the physical health (daily functioning and functional fitness) and mental health (depression and behavioral dysfunction) of older wheelchair users with dementia in long-term care facilities, examine the correlations between physical and mental health, and identify the independent variables of their daily functioning. METHODS: A descriptive correlational method was adopted, which was conducted in six long-term care facilities in three cities, south Taiwan. Participants comprised 98 older wheelchair users with dementia. Data were collected using structured questionnaires (Mini-Mental State Examination, Barthel Index, Cornell Scale for Depression in Dementia, and Clifton Assessment Procedures for the Elderly Behavior Rating Scale) and from functional fitness testing (cardiopulmonary functioning, body flexibility, joint mobility, and muscle strength and endurance). RESULTS: Older adults with dementia who had high depression scores were likely to have more behavioral dysfunctions, poorer performance in shoulder flexion and abduction, and lower upper limb muscle strength and endurance. More behavioral dysfunctions were associated with poorer daily functioning, lung capacity, body flexibility, shoulder flexion, and upper limb muscle strength and endurance. Those with better lung capacity, body flexibility, upper limb muscle strength, and endurance were likely to have high daily functioning scores (all p < .05). The key independent variables associated with daily functioning were behavioral dysfunction, lower body flexibility, and lung capacity, which together explained 59.3% of the total variance. CONCLUSIONS: Further research should develop appropriate activity-based intervention programs for older wheelchair users with dementia to delay their deterioration and promote their physical and mental health.

Barriers to Optimal Pain Management in Aged Care Facilities: An Australian Qualitative Study
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F. Veal, M. Williams, L. Bereznicki, et al.
Pain Manag Nurs 2018 Apr;19(2):177-185
Up to 80% of residents in aged care facilities (ACFs) experience pain, which is often suboptimally managed. The purpose of this study was to characterize pain management in ACFs and identify the barriers to optimal pain management. This exploratory descriptive qualitative study used semistructured interviews in five Southern Tasmania, Australian ACFs. Interviewees included 23 staff members (18 nurses and 5 facility managers) and were conducted from September to November 2015. Interviews included questions about how pain was measured or assessed, what happened if pain was identified, barriers to pain management, and potential ways to overcome these barriers. Interviewees noted that there were no formal requirements regarding pain assessment at the ACFs reviewed; however, pain was often informally assessed. Staff noted the importance of adequate pain management for the residents’ quality of life and employed both nonpharmacologic and pharmacologic techniques to reduce pain when identified. The barriers to optimal pain management included difficulty identifying and assessing pain, residents’ resistance to reporting pain and/or taking medications, and communication barriers between the nursing staff and GPs. Staff interviewed were dedicated to managing residents’ pain effectively; however, actions in a number of areas could improve resident outcomes. These include a more consistent approach to documenting pain in residents’ progress notes and improving nurse-GP communications to ensure that new or escalating pain is identified and expedient changes can be made to the resident’s management. Additionally, resident, family, nurse, and carer education, conducted within the facilities on a regular basis, could help improve the pain management of residents.

Qualitatively exploring the suitability of tablet computers to encourage participation with activities by people with moderate stage dementia
Non UofA Access

S. K. Smith, G. A. Mountain and R. J. Hawkins.
Dementia (London) 2018 Sep 30:1471301218802897
Opportunities to participate with enjoyable activities is one of the most frequently reported unmet needs by the person living with dementia. Enabling and intuitive technologies may offer accessible ways to engage with such activities. Objectives To explore how tablet computers might encourage participation in enjoyable activities by people with moderate levels of dementia and to consider how such technologies might be incorporated into the repertoire of activities currently provided through day care settings. Methods A focused visual ethnographic approach was developed specifically to meet the research objectives. Twelve participants attending a community day care centre and nine supporters (both volunteers and paid staff) consented to take part in the research. Technology facilitated group activity sessions took place twice a week for a period of four weeks and all were video recorded. FINDINGS: Video analysis demonstrated that the majority of people with dementia found the technology an effective means of participating in enjoyable activities. Analysis also revealed the extent to which participation relies on the existence of effective support. It showed how maintaining focus on retained strengths and abilities enabled the group overall to meet and often exceed their own and others perceived capacity to participate. Finally, analysis confirmed the importance of enjoyment of activities ‘in the moment’ and the need for those supporting people in the moderate stages of dementia to acknowledge and work with this. Conclusion The use of tablet computers to enhance participation in sociable and enjoyable activities in day care settings is realistic and achievable if supported appropriately.

Depression among older people living in care homes report (UK)

British Geriatrics Society
September 2018
Our aim was to promote awareness and understanding of the key features of best practice among practitioners, commissioners and policy-makers. Our objective was to explore the ways in which geriatricians and allied health professionals, and psychiatrists specialising in the care of older people, are working together to overcome the specific challenges that arise when treating depression in older people living in this community. We wanted to focus on those people whose physical and mental health needs are severe enough to require input from psychiatrists and from geriatricians, while fully recognising the key role GPs play in diagnosis and treatment.

We Can’t Address What We Don’t Measure Consistently. Building Consensus on Frailty in Canada

National Institute on Ageing
September 2018
Canadian Frailty Network recently commissioned a report from the National Institute on Ageing (NIA) exploring this issue. The NIA/CFN report We Can’t Address What We Don’t Measure Consistently: Building Consensus on Frailty in Canada, authored by Dr. Samir Sinha, Allan McKee, Ivy Wong, Julie Dunning, Michael Nicin, and Dr. John Muscedere, shows that frailty is a common condition more prevalent in older populations, which increases an individual’s risk of falls, emergency department visits, hospitalization, institutionalization, and death. Released September 24, 2018, the report also shows that proactively and consistently measuring frailty can help health care providers better support individuals living with frailty to remain as independent as possible.


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Patient Engagement for Beginners

Friday 26 Oct 13:00-14:00 MT
KT Canada
Research funders are increasingly supporting patient-oriented research that includes patients as partners. Health authorities and other service organizations are seeking input on decisions, from program design to policy. Patient outcomes improve when people are engaged in their care, but what does it mean to engage with patients across the health system and research? How do you evaluate this engagement and know that it had an impact?

Journal Selection into the Web of Science Core Collection

Thursday 18 October Cameron Library 3-10
Presenter: Marisa Ruccolo
Learn about the journal selection from Clarivate Analytics’ editorial team in indexing journals into the Web of Science’s Core Collection for journals with an Impact Factor and those without one, in Emerging Sources Citation Index. Marisa Ruccolo, from Clarivates Analytics, will explain the flow from submission to indexation and “temporary” refusal, the yearly title suppressions of predatory journals and examples of citation stacking, among other unethical behaviours of journal editorial boards. What type of peer reviewing is required and how Publons serves as a transparency and verification tool, confirmed by the publishers themselves.

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Congratulations. Your Study Went Nowhere

BBC Music website offers dementia lifeline

Scientists can’t take risks until they are in their 40s

5 tips to fight procrastination in grad school

Could it be that the Implementation Science community is becoming a reality in the UK?

Active Implementation can bring about lasting change

Care homes are alive with the sound of music

How can you network most effectively within your own institution?

This Ivy League food scientist was a media darling. He just submitted his resignation, the school says.

How to Avoid Idiots at Academic Conferences

In the Nursing Home, Empty Beds and Quiet Halls: Fewer patients are winding up in nursing homes, and hundreds of the facilities are closing each year (US)

The secret to improving health care

Mayo Clinic expert on caring for elderly: ‘We’re going to face a huge crisis’

The trouble with hospitalized seniors

More than a third of nurses have PTSD; a third of doctors are burned out. What are we doing about it?

Co-production from proposal to paper

An academic’s guide to writing well: Scholarly prose can be verbose and unclear, and can obscure the point you are trying to make. Joe Moran offers his top 10 tips for writing well

Hoaxers Slip Breastaurants and Dog-Park Sex Into Academic Journals

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Institute for Research on Public Policy (IRPP) is looking for a Deputy Editor

Montreal PQ
DEADLINE: 9 October
The Institute for Research on Public Policy (IRPP) is looking for a Deputy Editor for its award-winning digital magazine, Policy Options. Based in Montreal, the Deputy Editor will assist the Editor-in-Chief with the daily management of the content of the magazine, including editing, solicitation of submissions, and planning of future projects.

Knowledge Translation/Evaluation Associate

Alberta’s Tomorrow Project, Alberta Health Services, Calgary AB
DEADLINE: 9 October
Alberta’s Tomorrow Project (ATP) was launched in 2000 as a prospective cohort to examine the relationship between environmental, lifestyle, and genetic factors and the incidence of cancer and chronic diseases. The main responsibility of the KTE/Evaluation Associate is to develop and carry out stakeholder engagement plans and translate knowledge generated through ATP research as well as to ensure projects are informed by evidence/knowledge users. The successful incumbent will be involved in the development and implementation of participant and stakeholder engagement initiatives, translating knowledge generated through ATP data, and support program evaluation and research work. In addition, this position will provide support for other operational activities as required and provide the knowledge translation and evaluation perspective in other ATP projects.

WHO Director, Ageing and Life Course

Geneva, Switzerland
DEADLINE: 12 October
Ageing and Health has been identified as a key area of work in WHO’s General Programme of Work. The Department of Ageing and Life Course (ALC) coordinates this work with the aim of bringing about policy, legislative, programmatic and social change for people to experience the best possible trajectories of Healthy Ageing. This includes strategies to help people build and maintain capacity across their lives, and to help people with declines in capacity to compensate or adapt to these losses. To achieve this, WHO draws on the total assets of the Organization in a “whole of Organization” approach led by the ALC Department. This also entails close collaboration with all levels of government, civil society and academia.

OHRI Post-Doctoral Fellow

Supervisor Dr. Justin Presseau, Ottawa, ON
We are seeking a talented individual with ambitions to advance their scientific career by capitalizing on being involved in a funded multi-disciplinary project involving experts spanning health psychology, cognitive psychology, medical sociology, qualitative methods, questionnaire design and survey administration, critical care research, epidemiology as well as experts through experience and key stakeholder organizations. The successful candidate will have the opportunity to gain experience and expand their professional network through collaboration with investigators from a range of disciplines. Opportunities for professional development include publications, presentations at scientific conferences, involvement in grant writing, exposure to new methodological approaches, and interaction with health system stakeholders and families. Working primarily with Dr. Justin Presseau at OHRI and Dr. Michaël Chassé at the Centre Hospitalier Universitaire de Montréal, the candidate will be expected to play a substantive role in design, data collection, analysis and write up. The successful candidate will also be embedded within, and actively contribute to, the Centre for Implementation Research and Ottawa Psychology and Health Group. There will be flexibility to integrate the candidate’s own ideas and scope for leading side projects. The successful candidate will also can contribute to graduate student supervision. The appointment will be for two years with the possibility of extension.

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